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;WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4187 APPLICATION FOR PLUMBING PERMIT
ereby,-,pffirm that I have a certificate of-consent to self in- 76A667A
&Nrg,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified'copy thereof(Sec. 3800, Lab. C.) LJ
Policy No: Company COUNTY OF LOS ANGELES DEPT. OF,PUBLIC-WORKS
'Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
/
ri Certified copy is filed with the county building inspection ADDRESS ? A 4-
department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY �J .
Ddfe Applicant WATER CLOSET(TOILET) NEAREST (�'�'
if I .AAw
CERTIFICATE OF EXEMPTION FROM.WORKERS' BATH TUB CROSS ST..
COMPENSATION INSURANCE. SHOWER OWNER
(Th.is section need norbe cgmpleted if the work involved by, MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work'forwhich this per- SINKJCITY SS �R TEL.NO y�/�
mit is issued, I shall not pyrnrrl,
ny-person in any manner so J
as to become subject t t e ers'Compe ion Laws. DISHWASHER v
r CONTRACTORDate ` App CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT. If, after making this C90icatevEx- SWIMMING POOL RECEPTOR
empti.on,you should become subject to the Wo ers'Compen-• CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed.revok. STATE LIC.'
ed. WATER HEATER LICENSE NO. CLASS 1
LICENSED CONTRACTORS DECLARATION DISTRICT NOPROLE BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section.7000)of Division 3 of the Business OUTLETS OVER J t
and
Professions Code, and my license is in full force and ef- 5 PER SYSTEM FIN ��' VALID ION a
DATE
License Number------. ___—Lic. Class V
FI
Contractor, Date O
I am exempt under See. W
B.BP.C. for this reasonoil. Z
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plari check applicant
I hereby affirm that I am exempt from the Contractor's License Name• 5
Law for the following reason (Section 7031.5,, Business and
Professions Code): Address ACCT s
I, as owner of the property, will do the work and the City Tel..No.• 3064a
structure is not intended or offered for sale(Section 7044, ITEMS
Business and Professions Code).
CONSTRUCTION LENDING AGENCY , TOTAL 64 50
I hereby,offirm•that there is a construction lending agency for (:HECK 64e50
the performance of the work for which this permit is issued CHANGE(Sec. 3097, Civ. C.). �•
,
HANGE e G0
Lender's,Name 0000—CGO I 1/19/89
19/89
Lender's Address r
1 certify that I have read this application and state that the � J9 0-0&
above information-is correct.I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-melon6d property,or inspection purp"Date
+
SEE REVERSE FOR EXPLANATORY LANGUAGE
Ij
Signatute of r e /if
76A667-CE#817 4-64
APPLICATION FOR PLUMBING PERI IT
COUNTY. OF LOS. ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.LAMBIE. COUNTY ENGINEER ADDRESS
WILLIAM A.JENSEN.SUPT OF BUILDING LOCALITY r
FOR APPLICANT TO FML'IN NEO sT .
NUMBER FIXTURE OR ITEM EACH 'FEE
OWNER
WATER CLOSET 51.25 MiAIL
BATH TUB 1.25 ADDRESS
CITY . NO.
SHOWER 1.25
LAVATORY 1.25 CONTRACTOR
SINS 1.25 ADDRESS G
DISHWASHER1.25 CITY TEL. N _-,Af1
LAUNDRY.TUB 1.25 for STATE
BEGISTRA ON NO. n COUNTY ❑
CLOTHES WASHER 1.25
DISTRICT NO. GROUP ZONE PR SED BY
WATER HEATER 1.50
GAS SYSTEM OUTLETS 0
1.50 W��T gOVAL O
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD V
O
. F-
U
W
d
Z
7
v
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT 5 2 00UNDER SLAB WORK r�
ROUGH PLUMBING
TOTAL FEE GAS PIPING b
I' HEREBY ACKNOWLEDGE THAT '1 HAVE READ THIS 'APPLICATION GAS VENT
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I A THE LEGAL OWNER OR AND INTEND TO
RESIDE IN.THE ABOVE DE RIBS SIDENTI L PRO RT UTILITY CO.NOTIFIED
SIGNATURE
OF PER
MITTE FINAL
VALIDAT ROBERT A.WOOD
CK. M.O. CABH SUPERVISING MECHANICAL ENWR
LAC0 2 5 6 0 0 JUN $ 5 D 3, 5 N a
Y �